Smoker and ex-smoker reactions to cigarettes claiming reduced risk

The effect of cigarette modified risk claims and brand on perceived risk, product appeal, and use intentions

OBJECTIVES

No studies have examined the brand context in which modified risk claims appear on tobacco products. This study examines how marketing products with modified risk claims affects risk perceptions, appeal, and intentions among own-brand, other brand, and novel brand cigarettes.

METHODS

This experiment employed a 3 (claim: risk modification [RM], exposure modification [EM], control) x 3 (brand: own, other, novel) between-subjects design. A convenience sample (N = 1,557, Mage = 40.28, SDage = 19.01, 71.3% female, 80.3% White) of current or former Marlboro, Camel, or Newport users was collected. Participants were assigned to view their own brand, another brand, or a novel brand, with or without a claim, and rated perceived risk after switching to this product, product appeal, and use intentions.

RESULTS

Participants in the RM or EM conditions had lower risk perceptions (versus control). Claim did not affect appeal. Adult established cigarette users in the EM (but not RM) condition had higher intentions (versus control). Participants rated their own and another brand as more appealing than the novel brand. Interactions between brand and claim were not significant.

CONCLUSIONS

We found modified risk claims decreased risk perceptions but did not impact appeal. Whereas participants showed preference for their own brand in terms of appeal and intentions, brand did not moderate the impact of claims.

Perception and intention of using less harmful and less addictive hypothetical modified risk tobacco products among never tobacco users in the united states

AIMS

There is limited research focusing on how never tobacco users respond to claims associated with modified risk tobacco products (MRTPs). The purpose of the present study is twofold: (1) to identify how never tobacco users perceive hypothetical modified risk tobacco product (MRTP) claims; and (2) to assess whether these perceptions impact their intentions of using MRTPs described as "less harmful" and "less addictive."

METHOD

The present study draws upon a nationally representative dataset of US adults aged ≥ 18 years (n = 850) from a cross-sectional survey (HINTS-FDA, Cycle 2, 2017). Weighted unadjusted and adjusted logistic regression analyses were performed to analyze the data.

RESULTS

Participants who perceived tobacco products labeled as having "no additives" to be less harmful were close to three times more likely to report intentions of using "less harmful" (Adjusted OR = 2.93 [95% CI: 1.12-7.65]) and "less addictive" (Adjusted OR = 2.72 [95% CI: 1.03-7.21]) tobacco products than those who perceived them to be more/equally harmful. Participants who believed that tobacco products could be manufactured without some chemicals were over five and six times more likely to report intentions of using "less harmful" (Adjusted OR = 5.53 [95% CI: 1.59-19.25]) and "less addictive" (Adjusted OR = 6.60 [95% CI: 2.65-16.46]) tobacco products than those who were unlikely to believe it.

CONCLUSIONS

Our findings have implications for FDA's regulation of MRTPs and provides insights regarding how the marketing of authorized MRTPs could impact population health in the future.

Increasing socioeconomic disparities in tobacco smoking decline among French adolescents (2000-2017)

BACKGROUND

This paper studies the evolution of transitions from first cigarette use to daily use by socioeconomic status (SES) among French adolescents over the course of 17 years, in a context of decreasing prevalence of tobacco use.

METHODS

A total of 182 266 adolescents participated in the nationally representative ESCAPAD survey at nine different time points between 2000 and 2017. Discrete time-event analysis was used to model the transition to daily cigarette use as a function of SES, gender, age at onset and the use of other psychoactive substances.

RESULTS

Although lifetime cigarette smoking and daily cigarette smoking decreased significantly over the studied time span, suggesting a positive impact of prevention policies, disadvantaged adolescents were consistently more prone to engage in daily cigarette smoking, more so in 2017 than 15 years earlier. In the same time span, transitions from initiation to daily cigarette smoking have shortened, with an accelerated pace among underprivileged adolescents.

CONCLUSIONS

Accelerated transitions from initiation to daily cigarette use are a prevalent trend among disadvantaged adolescents in France. Efforts to mitigate the impact of marketing strategies and to promote health literacy should be pursued to reduce social inequalities in health.

Piloting a clinical laboratory method to evaluate the influence of potential modified risk tobacco products on smokers' quit-related motivation, choice, and behavior

Research methods are needed that can predict whether the availability of potential modified risk tobacco products (MRTPs) may influence smokers' quit-related motivation, choice, and behavior. This pilot study assessed the primary outcomes of feasibility and adherence to address this need using an electronic cigarette (ECIG) as a model MRTP. Cigarette smokers were randomly assigned to use only their own brand of cigarettes (OB-only) or a second-generation ECIG (18 ng/ml nicotine) plus their OB cigarettes (ECIG+OB) ad libitum for four weeks. Participants logged products using a mobile device, collected used cigarette filters, and provided saliva samples every day for analysis of cotinine. They returned to the lab once per week to provide a breath sample and accept or decline a choice to quit all tobacco products (i.e., cigarettes and/or ECIGs). They also returned for a one-month follow-up visit. Of those participants randomized (n = 60), 56.7% completed the 4-week intervention and 40.0% completed the follow-up visit. The primary reason for withdrawal was poor adherence with mobile device use. Comparable numbers of participants in each group chose to make a quit attempt, although more OB-only participants chose to quit during the first two weeks and more ECIG+OB participants during the last two weeks. With protocol modifications to reduce participation burden, the current method might ultimately be used by regulators to predict how smokers' quit-related motivation, choice, and behavior are influenced by current and future MRTPs.

US Adult Interest in Less Harmful and Less Addictive Hypothetical Modified Risk Tobacco Products

Introduction

Tobacco companies have a history of making health claims about their new products. Such claims are now regulated by the US Food and Drug Administration. We examined consumer interest in hypothetical modified risk tobacco products (MRTPs) among current, former, and never established smokers and examined whether interest was associated with beliefs about tobacco and cancer.

Methods

Data were analyzed from the US nationally representative 2015 Health Information National Trends Survey (HINTS-FDA 2015; N = 3738). Interest in hypothetical MRTPs was assessed by asking participants their likelihood of using tobacco products claiming to be less addictive and less harmful than other products.

Results

About half of current smokers and a tenth of both former and never smokers reported they were "somewhat" or "very" likely to try hypothetical MRTPs claiming to be less harmful or less addictive. Female smokers, former smokers with lower smoking harm perceptions, and never smokers who are young adults or without college education expressed more interest in these products. Interest in using these products was positively associated with believing that smoking status is a changeable individual characteristic and that it is possible for tobacco products to be made without some harmful chemicals.

Conclusion

We identified several subgroups of current, former, and never smokers who may be particularly affected by the marketing of MRTPs and therefore important to study to inform models of the potential population health impact of authorizing the marketing of MRTPs.

Implications

Findings about interest in hypothetical MRTPs can inform models of how the marketing of MRTPs could affect population health. Understanding which subgroups are particularly interested in MRTPs can help determine who might be important to study to inform these models. We identified several groups who may warrant specific attention: smokers who are female, former smokers who hold low harm perceptions of smoking, never smokers who are young adults or have a high school education or less, people who believe that smoking is a changeable individual characteristic, and people who believe that it is possible to make low chemical tobacco products.

Perceptions of Continued Smoking and Smoking Cessation Among Patients With Cancer

PURPOSE

Continued smoking after a cancer diagnosis leads to poorer treatment outcomes, survival, and quality of life. We evaluated the perceptions of the effects of continued smoking on quality of life, survival, and fatigue among patients with cancer after a cancer diagnosis and the effects of these perceptions on smoking cessation.

PATIENTS AND METHODS

Patients with cancer from all disease subsites from Princess Margaret Cancer Centre (Toronto, Ontario) were surveyed between April 2014 and May 2016 for sociodemographic variables, smoking history, and perceptions of continued smoking on quality of life, survival, and fatigue. Multivariable regression models evaluated the association between patients' perceptions and smoking cessation and the factors influencing patients' perceptions of smoking.

RESULTS

Among 1,121 patients, 277 (23%) were smoking cigarettes up to 1 year before diagnosis, and 54% subsequently quit; 23% had lung cancer, and 27% had head and neck cancers. The majority felt that continued smoking after a cancer diagnosis negatively affected quality of life (83%), survival (86%), and fatigue (82%). Current smokers during the peridiagnosis period were less likely to perceive that continued smoking was harmful when compared with ex-smokers and never-smokers ( P < .01). Among current smokers, perceiving that smoking negatively affected quality of life (adjusted odds ratio [aOR], 2.68 [95% CI, 1.26 to 5.72]; P = .011), survival (aOR, 5.00 [95% CI, 2.19 to 11.43]; P < .001), and fatigue (aOR, 3.57 [95% CI, 1.69 to 7.54]; P < .001) were each strongly associated with smoking cessation. Among all patients, those with a greater smoking history were less likely to believe that smoking was harmful in terms of quality of life (aOR, 0.98 [95% CI, 0.98 to 0.99]; P < .001), survival (aOR, 0.98 [95% CI, 0.98 to 0.99]; P < .001), and fatigue (aOR, 0.99 [95% CI, 0.98 to 0.99]; P < .001).

CONCLUSION

The perceptions of continued smoking after a cancer diagnosis among patients with cancer are strongly associated with smoking cessation. Counseling about the harms of continued smoking in patients with cancer, and in particular among those who have lower risk perceptions, should be considered when developing a smoking cessation program.

Adult interest in using a hypothetical modified risk tobacco product: findings from wave 1 of the Population Assessment of Tobacco and Health Study (2013-14)

BACKGROUND AND AIMS

The US Family Smoking Prevention and Tobacco Control Act provides a pathway for manufacturers to market a modified risk tobacco product (MRTP). This study examines socio-demographic and tobacco use correlates of interest in a hypothetical MRTP in a nationally representative sample of US adults.

DESIGN

Cross sectional wave 1 data from the 2013-14 Population Assessment of Tobacco and Health (PATH) Study.

SETTING

Household Audio-Computer Assisted Self-Interviews of US adults conducted in 2013-14.

PARTICIPANTS

A total of 32 320 civilian, non-institutionalized adults in the United States.

MEASUREMENTS

Interest in using a hypothetical MRTP ('If a tobacco product made a claim that it was less harmful to health than other tobacco products, how likely would you be to use that product?'), socio-demographics, tobacco use history and mental health and substance use problems. All estimates were weighted.

FINDINGS

Overall, 16.7% [95% confidence interval (CI) = 16.28, 17.18] of US adults reported interest in a hypothetical MRTP. Tobacco use was associated significantly with interest in a hypothetical MRTP, with interest most common among current established smokers (54.4%; 95% CI = 53.31, 55.39) and least common among never tobacco users (3.0%; 95% CI = 2.49, 3.55). Interest in a hypothetical MRTP was associated with experimental e-cigarette use among current experimental, current established and former smokers. Among non-smokers, race, age, education and substance use were associated with interest in using a hypothetical MRTP.

CONCLUSIONS

Among adults in the United States, interest in using a hypothetical modified risk tobacco product is low overall, and highest among current experimental and established smokers. A small percentage of non-smokers are interested in using a hypothetical hypothetical modified risk tobacco product.

Perceived nicotine content of reduced nicotine content cigarettes is a correlate of perceived health risks

BACKGROUND

Reducing cigarette nicotine content may reduce smoking. Studies suggest that smokers believe that nicotine plays a role in smoking-related morbidity. This may lead smokers to assume that reduced nicotine means reduced risk, and attenuate potential positive effects on smoking behaviour.

METHODS

Data came from a multisite randomised trial in which smokers were assigned to use cigarettes varying in nicotine content for 6 weeks. We evaluated associations between perceived and actual nicotine content with perceived health risks using linear regression, and associations between perceived nicotine content and perceived health risks with smoking outcomes using linear and logistic regression.

FINDINGS

Perceived-not actual-nicotine content was associated with perceived health risks; compared with those perceiving very low nicotine, individuals who perceived low (β=0.72, 95% CI 0.26 to 1.17), moderate (β=1.02, 95% CI 0.51 to 1.53) or high/very high nicotine (β=1.66, 95% CI 0.87 to 2.44) perceived greater health risks. Nevertheless, individuals perceiving low (OR=0.48, 95% CI 0.32 to 0.71) or moderate nicotine (OR=0.42, 95% CI 0.27 to 0.66) were less likely than those perceiving very low nicotine to report that they would quit within 1 year if only investigational cigarettes were available. Lower perceived risk of developing other cancers and heart disease was also associated with fewer cigarettes/day at week 6.

CONCLUSIONS

Although the perception of reduced nicotine is associated with a reduction in perceived harm, it may not attenuate the anticipated beneficial effects on smoking behaviour. These findings have implications for potential product standards targeting nicotine and highlight the need to clarify the persistent harms of reduced nicotine combusted tobacco products.

Reduced nicotine content cigarette advertising: How false beliefs and subjective ratings affect smoking behavior

INTRODUCTION

Tobacco advertising can create false beliefs about health harms that are reinforced by product design features. Reduced nicotine content (RNC) cigarettes may reduce harm, but research has not addressed advertising influences. This study examined RNC cigarette advertising effects on false harm beliefs, and how these beliefs - along with initial subjective ratings of RNC cigarettes - affect subsequent smoking behaviors. We further explored whether subjective ratings moderate associations between false beliefs and behavior.

METHODS

Seventy-seven daily, non-treatment-seeking smokers (66.2% male) participated in the first 15days of a randomized, controlled, open-label RNC cigarette trial. Participants viewed an RNC cigarette advertisement at baseline before completing a 5-day period of preferred brand cigarette use, followed by a 10-day period of RNC cigarette use (0.6mg nicotine yield). Participants provided pre- and post-advertisement beliefs, and subjective ratings and smoking behaviors for cigarettes smoked during laboratory visits.

RESULTS

Viewing the advertisement increased beliefs that RNC cigarettes contain less nicotine and are healthier than regular cigarettes (p's<0.001 and 0.011), and decreased the belief that they are less likely to cause cancer (p=0.046). Neither false beliefs nor subjective ratings directly affected smoking behaviors. Significant interactions of strength and taste ratings with beliefs (p's<0.001), however, indicated that among smokers with less negative initial subjective ratings, greater false beliefs were associated with greater RNC cigarette consumption.

CONCLUSIONS

Smokers may misconstrue RNC cigarettes as less harmful than regular cigarettes. These beliefs, in conjunction with favorable subjective ratings, may increase product use.

Website Use and Effects of Online Information About Tobacco Additives Among the Dutch General Population: A Randomized Controlled Trial

BACKGROUND

As a legal obligation, the Dutch government publishes online information about tobacco additives to make sure that it is publicly available. Little is known about the influence this website ("tabakinfo") has on visitors and how the website is evaluated by them.

OBJECTIVE

This study assesses how visitors use the website and its effect on their knowledge, risk perception, attitude, and smoking behavior. The study will also assess how the website is evaluated by visitors using a sample of the Dutch general population, including smokers and nonsmokers.

METHODS

A randomized controlled trial was conducted, recruiting participants from an online panel. At baseline, participants (N=672) were asked to fill out an online questionnaire about tobacco additives. Next, participants were randomly allocated to either one of two experimental groups and invited to visit the website providing information about tobacco additives (either with or without a database containing product-specific information) or to a control group that had no access to the website. After 3 months, follow-up measurements took place.

RESULTS

At follow-up (n=492), no statistically significant differences were found for knowledge, risk perception, attitude, or smoking behavior between the intervention and control groups. Website visits were positively related to younger participants (B=-0.07, 95% CI -0.12 to -0.01; t11=-2.43, P=.02) and having a low risk perception toward tobacco additives (B=-0.32, 95% CI -0.63 to -0.02; t11=-2.07, P=.04). In comparison, having a lower education (B=-0.67, 95% CI -1.14 to -0.17; t11=-2.65, P=.01) was a significant predictor for making less use of the website. Furthermore, the website was evaluated less positively by smokers compared to nonsmokers (t324=-3.55, P<.001), and males compared to females (t324=-2.21, P=.02).

CONCLUSIONS

The website did not change perceptions of tobacco additives or smoking behavior. Further research is necessary to find out how online information can be used to effectively communication about the risks of tobacco additives.

TRIAL REGISTRATION

Nederlands Trial Register NTR4620; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4620 (Archived by WebCite at http://www.webcitation.org/6oW7w4Gnj).

U.S. adults' addiction and harm beliefs about nicotine and low nicotine cigarettes

This research described U.S. adults' beliefs about nicotine and low nicotine cigarettes (LNCs) using the nationally-representative Health Information National Trends Survey (HINTS-FDA 2015; N=3738). About three quarters of people either were unsure of the relationship between nicotine and cancer or incorrectly believed that nicotine causes cancer. People who were non-White, less educated, age 65+, and never established smokers were most likely to be unaware that nicotine is not a cause of cancer. More than a quarter of people held the potentially inaccurate beliefs that LNCs would be less harmful and addictive than typical cigarettes. Whites were more likely than Blacks to believe LNCs were less harmful than typical cigarettes, and never smokers were more likely to believe this than established quitters. Whites and people with at least a college degree were more likely to believe that LNCs would be less addictive than typical cigarettes. Overall, we found that many people, particularly the demographic subgroups identified here, held incorrect beliefs about nicotine and potentially inaccurate beliefs about LNCs. Findings should be considered in assessing the public health impact of marketing low nicotine products. Incorrectly believing that nicotine causes cancer could discourage smokers from switching to safer nicotine-containing alternatives, and could lead nonsmokers to experiment with low nicotine tobacco products, believing that cancer risk would be reduced. Findings underscore the need to educate the public on the health effects of nicotine and LNCs, and can help public health practitioners determine which subgroups should be prioritized in targeted educational efforts.

Misperceptions of harm among Natural American Spirit smokers: results from wave 1 of the Population Assessment of Tobacco and Health (PATH) study (2013-2014)

INTRODUCTION

This study estimated differences in cigarette harm perceptions among smokers of the Natural American Spirit (NAS) brand-marketed as 'natural', 'organic' and 'additive-free'-compared to other smokers, and examined correlates of NAS use.

METHODS

Data were drawn from wave 1 of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative study of US adults (2013-2014). Weighted analyses using a subset of current adult smokers (n=10 565) estimated the prevalence of NAS use (vs all other brands) and examined associations between NAS use and sociodemographics, tobacco/substance use, tobacco harm perceptions, quit intentions, quit attempts and mental/behavioural health.

RESULTS

Overall, 2.3% of adult smokers (920 000 people in the USA) reported NAS as their usual brand. Nearly 64% of NAS smokers inaccurately believed that their brand is less harmful than other brands compared to 8.3% of smokers of other brands, after controlling for potential confounders (aOR 22.82). Younger age (18-34 vs 35+; aOR 1.54), frequent thinking about tobacco harms (aOR 1.84), past 30-day alcohol use (aOR 1.57), past 30-day marijuana use (aOR 1.87) and sexual orientation (lesbian, gay, bisexual, 'other' or 'questioning' vs heterosexual; aOR 2.07) were also associated with increased odds of smoking NAS.

CONCLUSIONS

The majority of NAS smokers inaccurately believes that their cigarettes are less harmful than other brands. Given the brand's rapid growth and its more common use in vulnerable groups (eg, young adults, lesbian, gay, bisexual, 'other' or 'questioning' adults), corrective messaging and enforcement action are necessary to correct harm misperceptions of NAS cigarettes.

Expanding clinical laboratory tobacco product evaluation methods to loose-leaf tobacco vaporizers

BACKGROUND

Novel tobacco products entering the US market include electronic cigarettes (ECIGs) and products advertised to "heat, not burn" tobacco. There is a growing literature regarding the acute effects of ECIGs. Less is known about "heat, not burn" products. This study's purpose was to expand existing clinical laboratory methods to examine, in cigarette smokers, the acute effects of a "heat, not burn" "loose-leaf tobacco vaporizer" (LLTV).

METHODS

Plasma nicotine and breath carbon monoxide (CO) concentration and tobacco abstinence symptom severity were measured before and after two 10-puff (30-s interpuff interval) product use bouts separated by 60min. LLTV effects were compared to participants' own brand (OB) cigarettes and an ECIG (3.3V; 1.5ohm; 18mg/ml nicotine).

RESULTS

Relative to OB, LLTV increased plasma nicotine concentration to a lesser degree, did not increase CO, and did not appear to reduce abstinence symptoms as effectively. Relative to ECIG, LLTV nicotine and CO delivery and abstinence symptom suppression did not differ. Participants reported that both the LLTV and ECIG were significantly less satisfying than OB.

CONCLUSIONS

Results demonstrate that LLTVs are capable of delivering nicotine and suppressing tobacco abstinence symptoms partially; acute effects of these products can be evaluated using existing clinical laboratory methods. Results can inform tobacco product regulation and may be predictive of the extent that these products have the potential to benefit or harm overall public health.

Using eye-tracking to examine how embedding risk corrective statements improves cigarette risk beliefs: Implications for tobacco regulatory policy

BACKGROUND

Tobacco companies have deliberately used explicit and implicit misleading information in marketing campaigns. The aim of the current study was to experimentally investigate whether the editing of explicit and implicit content of a print advertisement improves smokers' risk beliefs and smokers' knowledge of explicit and implicit information.

METHODS

Using a 2(explicit/implicit)×2(accurate/misleading) between-subject design, 203 smokers were randomly assigned to one of four advertisement conditions. The manipulation of graphic content was examined as an implicit factor to convey product harm. The inclusion of a text corrective in the body of the ad was defined as the manipulated explicit factor. Participants' eye movements and risk beliefs/recall were measured during and after ad exposure, respectively.

RESULTS

Results indicate that exposure to a text corrective decreases false beliefs about the product (p<.01) and improves correct recall of information provided by the corrective (p<.05). Accurate graphic content did not alter the harmfulness of the product. Independent of condition, smokers who focused longer on the warning label made fewer false inferences about the product (p=.01) and were more likely to correctly recall the warning information (p<.01). Nonetheless, most smokers largely ignored the text warning.

CONCLUSIONS

Embedding a corrective statement in the body of the ad is an effective strategy to convey health information to consumers, which can be mandated under the Tobacco Control Act. Eye-tracking results objectively demonstrate that text-only warnings are not viewed by smokers, thus minimizing their effectiveness for conveying risk information.

Risk perceptions of smokeless tobacco among adolescent and adult users and nonusers

The recent growth in smokeless tobacco (ST) consumption has raised questions about consumer risk perceptions of ST products, especially in high-risk vulnerable populations. This qualitative study examined risk perceptions of ST among adolescent and adult users and nonusers in Ohio Appalachia. Focus groups and interviews were held with adolescents (n = 53; M age = 17 years) and adults (n = 63; M age = 34 years) from four Ohio Appalachian counties. Participants were asked about their perceptions of ST-related health risks, ST safety, and the relative safety of ST compared with cigarettes. Transcriptions were coded independently by two individuals. Overall, participants were knowledgeable about health problems from ST use (e.g., oral cancers, periodontal disease). Nearly all participants stated that ST use is not safe; however, there was disagreement about its relative safety. Some perceived all tobacco products as equally harmful; others believed that ST is safer than cigarettes for either the user or those around the user. Disagreements about ST relative safety may reflect mixed public health messages concerning the safety of ST. Comprehensive consumer messages about the relative safety of ST compared with cigarettes are needed. Messages should address the effect of ST on the health of the user as well as those exposed to the user.

Reduced nicotine product standards for combustible tobacco: building an empirical basis for effective regulation

INTRODUCTION

Both the Tobacco Control Act in the U.S. and Article 9 of the Framework Convention on Tobacco Control enable governments to directly address the addictiveness of combustible tobacco by reducing nicotine through product standards. Although nicotine may have some harmful effects, the detrimental health effects of smoked tobacco are primarily due to non-nicotine constituents. Hence, the health effects of nicotine reduction would likely be determined by changes in behavior that result in changes in smoke exposure.

METHODS

Herein, we review the current evidence on nicotine reduction and discuss some of the challenges in establishing the empirical basis for regulatory decisions.

RESULTS

To date, research suggests that very low nicotine content cigarettes produce a desirable set of outcomes, including reduced exposure to nicotine, reduced smoking, and reduced dependence, without significant safety concerns. However, much is still unknown, including the effects of gradual versus abrupt changes in nicotine content, effects in vulnerable populations, and impact on youth.

DISCUSSION

A coordinated effort must be made to provide the best possible scientific basis for regulatory decisions. The outcome of this effort may provide the foundation for a novel approach to tobacco control that dramatically reduces the devastating health consequences of smoked tobacco.

Initial puffing behaviors and subjective responses differ between an electronic nicotine delivery system and traditional cigarettes

Background

Electronic nicotine delivery systems (ENDS) present an emerging issue for tobacco control and data on product use behaviors are limited.

Methods

Participants (N = 38 enrolled; N = 16 compliant) completed three lab visits over 5 days and were asked to abstain from regular cigarettes for 72 hours in favor of ENDS (Smoke 51 TRIO – 3 piece, First Generation with 11 mg/ml filters). Lab visits included measurement of exhaled carbon monoxide (CO) and salivary cotinine concentration, questionnaire measures of regular cigarette craving after the 72 hour abstinence, and subjective product effects. Participants used a topography device to record puff volume, duration, flow rate, and inter-puff interval.

Results

Analyses revealed significant differences across products in puff count, average volume, total volume and inter-puff interval, with ENDS broadly showing a more intensive smoking pattern. Cigarette craving scores dropped significantly after smoking regular cigarettes, but not ENDS (p = .001), and subjective measures showed ENDS rated less favorably. CO boost, after ENDS use, decreased significantly (p < .001), and saliva cotinine significantly dropped between visits 1 and 3 (p < 0.001) after ENDS use relative to after cigarette smoking. For compliant and non-compliant participants, there was an average 82.0% [V1 - 16.1 cpd; V3 - 2.9 cpd] and average 73.9% [V1 - 20.3 cpd; V3 - 5.3 cpd] reduction in regular cigarette use per day during the ENDS trial period, respectively.

Conclusions

The ENDS were smoked more intensively than own brand cigarettes, but delivered significantly less nicotineand were less satisfying. These findings have implications for the viability of certain ENDS as alternatives to cigarettes.

Smokers' risk perception, socioeconomic status and source of information on cancer

BACKGROUND

In many countries, the decline in smoking prevalence has coincided with a growing concentration of smoking among people with lower socioeconomic status (SES). This concentration may reflect the social differentiation of risk perceptions. We investigated the factors associated with risk perception and fear of cancer, paying particular attention to SES indicators and health information seeking.

METHODOLOGY

A cross-sectional telephone survey conducted in France in 2010 (including 826 current smokers aged 18-75) assessing how smokers perceive the risk of smoking-related cancer in terms of daily consumption and duration thresholds.

RESULTS

Among current smokers, 38% considered that smoking can cause cancer only for a daily consumption higher than their own consumption, and an additional 22% stated that tobacco-related cancer risk only becomes high for a longer smoking duration than their personal one. Predictors of such risk perceptions included low SES, material deprivation and mentioning either the internet or their relatives as one's main source of information on cancer. The same characteristics were also predictive of personal fear of tobacco-related cancer.

CONCLUSION

Our results illustrate the challenges faced by prevention campaigns in the internet society, as information found on the web may fuel smokers' risk denial. Anti-tobacco policies should tailor interventions to people with low SES, who may be especially impervious to standard prevention campaigns because of material deprivation, and they should also address and challenge smokers' risk denial beliefs.

Cigarette smokers' use of unconventional tobacco products and associations with quitting activity: findings from the ITC-4 U.S. cohort

INTRODUCTION

The purpose of this study was to evaluate the prevalence and correlates of use of nicotine-containing tobacco products such as cigars, pipe tobacco, and cigarettes that promise less exposure to toxins; e-cigarettes; and smokeless tobacco products among a cohort of conventional cigarette smokers followed over the past decade. We also evaluated associations between use of such products and cigarette quitting.

METHODS

Participants were 6,110 adult smokers in the United States, who were interviewed as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Respondents reported their concurrent use of other smoked tobacco products (including cigars, pipe tobacco, and cigarillos), smokeless tobacco products (including chewing tobacco, snus, and snuff), unconventional cigarettes (including Omni, Accord, and Eclipse), and electronic cigarettes. Prevalence and correlates of use and associations between use and cigarette quitting were assessed using regression analyses via generalized estimating equations.

RESULTS

Most cigarette smokers did not use unconventional tobacco products, although use of any of these products started to rise at the end of the study period (2011). For each type of tobacco product evaluated, use was most prevalent among those aged 18-24 years. Smokers who did use unconventional tobacco products did not experience a clear cessation advantage.

CONCLUSIONS

During the past decade, relatively few cigarette smokers reported also using other tobacco products. Those that did use such products were no more likely to stop using conventional cigarettes compared with those who did not use such products.

Effects of smoking cues and argument strength of antismoking advertisements on former smokers' self-efficacy, attitude, and intention to refrain from smoking

INTRODUCTION

This study examines the impact of smoking cues employed in antismoking advertisements on former smokers. Previous findings indicate that visual smoking cues in antismoking advertisements with weak antismoking arguments can elicit smoking urges in smokers and undermine message effectiveness. This study extends these observations to former smokers asking whether smoking cues in antismoking advertisements influence former smokers' self-efficacy, attitudes, and intention to refrain from smoking, along with smoking urges and perceived message effectiveness.

METHODS

The study was a mixed 2 (smoking cues; present vs. absent) × 2 (argument strength [AS]; high vs. low) design where smoking cue was a between-subject factor and AS was a within-subject factor. Potential participants recruited via online ads were screened in a phone interview for their eligibility. A total of 105 former smokers (aged 21-65) participated in the study, which was conducted in a laboratory setting. Repeated measure ANOVA and MANOVA were used for the analyses.

RESULTS

The results showed that the presence of smoking cues in antismoking ads undermines former smokers' behavioral self-efficacy, attitude, and intention about smoking abstinence, which increased as AS for the ads increased. Former smokers' reports of smoking urge were not affected by smoking cues or AS. However, consistent with previous findings for smokers, the presence of cues weakened perceived message effectiveness of antismoking ads rated by former smokers.

CONCLUSIONS

The effect of smoking cues on former smokers' self-efficacy, attitude, and intention to refrain from smoking is problematic. Inclusion of smoking cues in antismoking ads should be undertaken only when accompanied by strong arguments.

Socioeconomic, demographic and smoking-related correlates of the use of potentially reduced exposure to tobacco products in a national sample

BACKGROUND AND AIM

In recent years, new non-traditional, potentially reduced exposure products (PREPs), claiming to contain fewer harmful chemicals than the traditional products, have been introduced in the market. Little is known about socioeconomic, demographic and smoking-related determinants of the likelihood of using these products among smokers. The aim of this study was to examine these determinants.

METHODS

Data from the 2006-2007 Tobacco Use Supplement to the Current Population Survey was used. We limited the analysis to current smokers (n=40724). Multivariate logistic regression analyses were conducted to estimate the association between covariates and the probability of the use of PREPs.

RESULTS

We found that younger age, lower education, higher nicotine addiction and having an intention to quit are associated with higher likelihood of the use of PREPs. The likelihood of using these products was found to be higher among respondents who are unemployed or have a service, production, sales or farming occupation than those with a professional occupation. Smokers living in the midwest, south or west, were found to have a greater likelihood of the use of PREPs than those living in the northeast.

CONCLUSIONS

Because there is little evidence to suggest that PREPs are less harmful that other tobacco products, their marketing as harm-minimising products should be regulated. Smokers, in particular those who are younger, have a lower socioeconomic status, and are more nicotine-dependent, should be the target of educational programmes that reveal the actual harm of PREPs.

Postmarketing surveillance for "modified-risk" tobacco products

INTRODUCTION

The U.S. Food and Drug Administration (FDA) acquired authority to regulate tobacco products in 2009. This authority will provide a structured process for manufacturers to introduce products that may have "modified-risk" for morbidity or mortality relative to traditional tobacco products, with postmarketing surveillance and studies a condition of marketing.

METHOD

A narrative review approach was taken. The author searched and integrated publicly accessible literature on tobacco product surveillance as well as drug and medical device postmarket activities currently performed by FDA.

RESULTS

FDA relies on active and passive methods for postmarket surveillance and can require specific studies and risk evaluation and mitigation strategies for certain products, including those with abuse liability. Past efforts at examining the individual and population effects of reduced harm tobacco products provide an example of integrating different data streams.

DISCUSSION

Postmarket surveillance can be viewed in terms of the Agent-Host-Vector-Environment model, and concepts from diffusion of innovations are relevant to understanding factors associated with the adoption of new products by the population. Given that active and passive surveillance approaches have different strengths and weaknesses, multiple approaches may be necessary to evaluate population-level effects. Assuring that required studies are properly conducted and reported and that data indicating significant public health harms are quickly recognized will be important going forward.

CONCLUSIONS

The advent of broad regulatory authority over tobacco provides opportunities for policy evaluation research. The research community can provide FDA with the independent science it needs to evaluate the public health impact of novel tobacco products.

Widening inequalities in smoking initiation and cessation patterns: a cohort and gender analysis in France

AIMS

This study investigates the evolution of educational inequalities in smoking initiation and cessation in France according to gender and birth cohort.

METHODS

We used a 2005 nationwide survey comprising 25,239 subjects aged 18-75 years. Three cohort groups were defined (born 1930-1945, 1946-1965 or 1966-1987). We compared their smoking histories until age 40 years with time-discrete logistic regressions. Educational differences in initiation and cessation were quantified using odds ratios and relative indices of inequality (RII), and the gender gap using odds ratios (gender ratios).

RESULTS

For smoking initiation, in the oldest cohorts, no educational gradient appeared in men, but there was a positive gradient in women (RII=0.19); in the middle cohorts, a negative gradient emerged in men (RII=1.55), while the positive gradient reduced in women (RII=0.74); in the youngest cohorts, there was a strengthening of the negative gradient in men (RII=2.72), and the emergence of a negative gradient for women (RII=1.86). The gender ratio narrowed from the oldest cohorts (3.23) to the youngest (1.09), and diminished with increasing educational level within each cohort. For smoking cessation, the educational gradients were negative in both genders, with wider gaps in the youngest cohorts, and gender ratios below 1 reflecting more marked cessation dynamics in women.

CONCLUSION

Women are at an earlier stage in the tobacco epidemic than men for initiation and at a later stage for cessation and social inequalities are widening. We believe that they will not decrease unless gender and the psycho-social aspects of smoking are considered in prevention campaigns.

Social gradient in initiation and transition to daily use of tobacco and cannabis during adolescence: a retrospective cohort study

AIMS

This study explores whether the family socio-economic status (F-SES) and school situation could have an impact on tobacco and cannabis initiation and transition to daily use during adolescence.

DESIGN AND SETTING

A French cross-sectional nation-wide survey conducted in 2005 containing retrospective data.

PARTICIPANTS

French teenagers aged 17 (n = 29 393).

MEASUREMENT

The F-SES was defined by the highest occupational category of either parent, with seven categories ranging from unemployed/inactive to managers/professionals. Ages at repeat school years, at leaving school, at the first episode of drunkenness and at initiation of illicit drug use were used to model tobacco and cannabis initiation and transition to daily use with time-discrete logistic regressions.

FINDINGS

The risk for tobacco initiation was almost equally distributed across F-SES groups, but the risk of a progression to daily use was higher in every F-SES category compared to managers/professionals [odds ratio (OR) from 1.17 to 1.90]. Compared to managers/professionals, risk of cannabis initiation was lower in all F-SES categories (OR from 0.63 to 0.87), but all categories except farmers were at increased risk of transition to daily use: the OR range between 1.29 (intermediate) and 1.98 (unemployed/inactive). Repeating school years and leaving school predicted daily use of tobacco (OR = 2.00 and 2.37) and cannabis (4.58 and 2.07).

CONCLUSIONS

Adolescents from the highest family socio-economic status categories are at risk for tobacco and cannabis experimentation but are less prone to engage in daily use. Psychological and social mechanisms that inhibit transition to daily use should be investigated, including school attainment and performance.

A pilot randomized study of smokeless tobacco use among smokers not interested in quitting: changes in smoking behavior and readiness to quit

INTRODUCTION

Several prior studies suggest that smokeless tobacco use results in less carcinogenic risk than does cigarette smoking. Whether smokers will use smokeless tobacco is unclear, as is the impact of such use on long-term smoking behavior and cessation. It is equally plausible that smokeless tobacco use among smokers could either (a) increase total tobacco exposure and undermine motivation to quit or (b) decrease overall tobacco exposure, motivate smokers to quit, and enhance cessation. Either outcome is of major public health significance.

METHODS

In this small (N = 31), short-term (2 week) pilot study, smokers uninterested in quitting were randomized to (a) receive Ariva or Stonewall (both spitless and smokeless tobacco lozenges) or (b) continue smoking conventional cigarettes.

RESULTS

Ariva/Stonewall use led to a significant reduction (40%, 95% CI: 24%-55%) in cigarettes per day, no significant increases in total tobacco use (cigarettes + Ariva/Stonewall; p > .05), and significant increases in two measures of readiness to quit, either in the next month (p < .001) or within the next 6 months (p = .04), as well as significant increases in self-efficacy to quit smoking (p < .001). No such changes were found among smokers maintained on conventional cigarettes.

DISCUSSION

These results suggest no deleterious effect on short-term smoking and quitting behavior among smokers who use smokeless tobacco. More broadly, this study suggests a strong need for a large prospective randomized clinical trial to more accurately assess the long-term viability of smokeless tobacco use as a method for cessation induction among unmotivated smokers.

Surveillance methods for identifying, characterizing, and monitoring tobacco products: potential reduced exposure products as an example

Tobacco products are widely sold and marketed, yet integrated data systems for identifying, tracking, and characterizing products are lacking. Tobacco manufacturers recently have developed potential reduced exposure products (PREP) with implied or explicit health claims. Currently, a systematic approach for identifying, defining, and evaluating PREPs sold at the local, state, or national levels in the United States has not been developed. Identifying, characterizing, and monitoring new tobacco products could be greatly enhanced with a responsive surveillance system. This article critically reviews available surveillance data sources for identifying and tracking tobacco products, including PREPs, evaluating strengths and weaknesses of potential data sources in light of their reliability and validity. With the absence of regulations mandating disclosure of product-specific information, it is likely that public health officials will need to rely on a variety of imperfect data sources to help identify, characterize, and monitor tobacco products, including PREPs.

Characteristics of current and recent former smokers associated with the use of new potential reduced-exposure tobacco products

OBJECTIVES

To identify sociodemographic characteristics associated with having tried a potentialy reduced-exposure tobacco product (PREP) and to compare the smoking and quitting behaviors and attitudes of smokers who have tried a PREP product with non-PREP users.

METHODS

Analysis is based on a sample of 43,419 current and recent former smokers from the 2003 Tobacco Use Supplement to the Current Population Survey.

RESULTS

Overall, PREP use is low (2.5%). Current daily and someday only smokers have higher rates of use (2.9% and 2.4%, respectively) compared with former smokers (1.5%). PREP use is higher in southern states and among younger smokers, non-Hispanic Whites, and those with some college education. Smokers who have tried a PREP product are more likely to smoke light or ultra-light cigarettes, report more symptoms of nicotine dependence, smoke more cigarettes per day, report a higher number of quit attempts, and seek quitting assistance from pharmacotherapy and behavioral therapies compared with non-PREP users.

DISCUSSION

These findings support the concern that current smokers who are highly dependent yet motivated to quit smoking may seek PREPs as an alternative strategy to smoking cessation.

Surveillance indicators for potential reduced exposure products (PREPs): developing survey items to measure awareness

Background

Over the past decade, tobacco companies have introduced cigarettes and smokeless tobacco products (known as Potential Reduced Exposure Products, PREPs) with purportedly lower levels of some toxins than conventional cigarettes and smokeless products. It is essential that public health agencies monitor awareness, interest, use, and perceptions of these products so that their impact on population health can be detected at the earliest stages.

Methods

This paper reviews and critiques existing strategies for measuring awareness of PREPs from 16 published and unpublished studies. From these measures, we developed new surveillance items and subjected them to two rounds of cognitive testing, a common and accepted method for evaluating questionnaire wording.

Results

Our review suggests that high levels of awareness of PREPs reported in some studies are likely to be inaccurate. Two likely sources of inaccuracy in awareness measures were identified: 1) the tendency of respondents to misclassify "no additive" and "natural" cigarettes as PREPs and 2) the tendency of respondents to mistakenly report awareness as a result of confusion between PREPs brands and similarly named familiar products, for example, Eclipse chewing gum and Accord automobiles.

Conclusion

After evaluating new measures with cognitive interviews, we conclude that as of winter 2006, awareness of reduced exposure products among U.S. smokers was likely to be between 1% and 8%, with the higher estimates for some products occurring in test markets. Recommended measurement strategies for future surveys are presented.

Cigarettes and social differentiation in France: is tobacco use increasingly concentrated among the poor?

AIMS

This paper aimed to assess whether the increase of social differentiation of smoking is observed in France.

DESIGN AND SETTING

Five cross-sectional telephone surveys conducted in France between 2000 and 2007.

PARTICIPANTS

The surveys were conducted among national representative samples of French subjects aged 18-75 years (n=12 256, n=2906, n=27 499, n=2887, n=6007 in 2000, 2003, 2005, 2006 and 2007, respectively). We focused on three groups: executives, manual workers and the unemployed.

MEASUREMENTS

Time trends of smoking prevalence were assessed, and socio-economic factors (especially occupation and job status) associated with smoking were identified and compared in 2000 and 2005. We also computed respondents' equivalized household consumption (EHI) and their cigarette budget to assess the financial burden of smoking.

FINDINGS

Between 2000 and 2007, smoking prevalence decreased by 22% among executive managers and professionals and by 11% among manual workers, and did not decrease among the unemployed. Indicators of an underprivileged social situation were associated more markedly with smoking in 2005 than in 2000. In addition, the falling-off of smoking initiation occurred later and was less marked among manual workers than it was among executive managers and professionals. Finally, in 2005 15% of French smokers devoted at least 20% of their EHI to the purchase of cigarettes, versus only 5% in 2000, and smoking weighted increasingly heavily on the poorest smokers' budgets.

CONCLUSIONS

While these results point out an increased social differentiation in tobacco use, they underline the need to design and implement other forms of action to encourage people to quit, in particular targeting individuals belonging to underprivileged groups.

[Strategies for reducing risks in smoking: opportunity or threat]

The smoking control policies recommended by the World Health Organisation have achieved a slight decrease in smoking prevalence in the developed countries, although associated mortality is still very high. The use of tobacco products other than cigarettes and even medicinal nicotine (known as nicotine replacement therapy (NRT)) has been proposed as a risk reduction strategy. Among the tobacco products with less individual risk than cigarettes would be any type of tobacco without smoke (smokeless) with a low content in nitrosamines and modified cigarettes; both forms included under the PREP (Potentially Reduced Exposure Products) concept. The idea would be to promote these products among those who cannot quit smoking or wish to reduce their risk without giving up nicotine intake. The possible effects of risk reduction strategies, including PREP, on the decreased prevalence and morbidity and mortality are reviewed, and the possible implications that this measure could have in our country are analysed. Tobacco control measures in Spain are recent and still insufficient. Therefore, the current priority in Spain is the development of policies of control that have shown to more than effective. The marketing and advertising of new tobacco products, even with reduced potential risk, seems more a serious threat than an opportunity for the development of smoking control policies.

The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US

The issues related to tobacco harm reduction continue to challenge the tobacco control research and policy communities. The potential for combusting tobacco products to reduce exposure and risk remains largely unknown, but this has not stopped manufacturers from offering such products making these claims. The role of oral tobacco products in a harm reduction regimen has also been a source of dialogue and debate. Within the last few years, major cigarette manufacturing companies have begun selling smokeless products for the first time, claiming to target current cigarette smokers. Other cigarette manufacturers are also offering smokeless products in markets around the world. The harm reduction debate has at times been divisive. There has been no unifying set of principles or goals articulated to guide tobacco control efforts. In particular, the research needs are extraordinarily high in order to drive evidence-based policy in this area and avoid the mistakes made with "light" cigarettes. This paper discusses recommendations from a strategic dialogue held with key, mostly US-based tobacco control researchers and policy makers to develop a strategic vision and blueprint for research, policy and communications to reduce the harm from tobacco for the US. Short-term and long-term objectives are described.

Consumer awareness and attitudes related to new potential reduced-exposure tobacco product brands

INTRODUCTION

In recent years, there has been a proliferation of potential reduced-exposure tobacco products (PREPs) marketed that claim to be less harmful or less addictive, compared with conventional cigarettes. Tobacco control scientists have raised concerns about the potential adverse impact of marketing of these products for smoking prevention and cessation efforts. Although these products have not been widely used among smokers, there are few data available on consumers' awareness and attitudes toward these products.

METHODS

Data were obtained from the 2003 and 2005 Health Information National Trends Survey, a nationally representative telephone survey of adults 18 years and older regarding health communication and associated beliefs and behaviors. Our study population consisted of 6,369 respondents in 2003 and 5,586 respondents in 2005, of whom 19% were current smokers and 28% were former smokers.

RESULTS

In 2005, 45% of respondents had heard of at least one PREP product, while only 4.8% had actually tried one. Awareness and use were substantially higher among current smokers (55.6% and 12.7%). Awareness was highest for Marlboro Ultra Smooth (MUS) (30.2%), Eclipse (18.2%), Quest (7.8%), and Ariva (5.4%), while less than 2% for any other product. Of respondents who had tried a PREP, 50% cited harm reduction or assistance in quitting as a reason for trying the product and 30% believed that the product was less harmful than their usual brand. In the combined 2003 and 2005 dataset, 54.4% of current smokers stated that they would be "very" or "somewhat" interested in trying a cigarette advertised as less harmful, while only 3.2% of former smokers and 1.1% of never-smokers were interested. Among current smokers, interest was higher in females and non-Hispanic Whites, and among daily smokers, those who smoked 20 or more cigarettes per day and those who were not considering quitting. Smokers interested in PREPs were substantially more likely to rate their perceived lung cancer risk as high (40.3% vs. 8.3%) and to worry frequently about developing lung cancer (19.7% vs. 4%).

DISCUSSION

These results suggest that there is a substantial level of interest among current smokers in cigarettes marketed with claims of reduced exposure or harm. Of particular concern is that "health conscious" smokers and heavy smokers not planning to quit may be especially vulnerable to PREP marketing messages and view such products as an alternative to smoking cessation.

PREP advertisement features affect smokers' beliefs regarding potential harm

BACKGROUND

The Institute of Medicine report on potential reduced exposure products (PREPs) recommends that advertising and labelling be regulated to prevent explicitly or implicitly false or misleading claims. Belief that a product is less harmful may increase use or prevent smoking cessation.

OBJECTIVE

To determine the effect of altering advertisement features on smokers' beliefs of the harm exposure from a PREP.

METHODS

A Quest advertisement was digitally altered using computer software and presented to participants using web-based television recruitment contracted through a survey company. 500 current smokers completed demographic and smoking history questions, were randomised to view one of three advertisement conditions, then completed eight items assessing their beliefs of the harmfulness of the product. Advertisement conditions included the original, unaltered advertisement; a "red" condition where the cigarette packages were digitally altered to the colour red, implying increased harm potential; and a "no text" condition where all text was removed to reduce explicit product information. Polytomous logistic regression, using "incorrect," "unsure" and "correct" as outcomes, and advertisement type and covariates as predictors, was used for analyses.

RESULTS

Participants randomised to the "no text" advertisement were less likely to be incorrect in their beliefs that Quest cigarettes are lower in tar, less addictive, less likely to cause cancer, have fewer chemicals, are healthier and make smoking safer.

CONCLUSIONS

Smokers can form false beliefs about the harmfulness of PREP products based on how the PREPs are marketed. Careful examination must be undertaken to provide empirical evidence to better formulate regulatory principles of PREP advertising.

"Not one single case of throat irritation": misuse of the image of the otolaryngologist in cigarette advertising

Early in the last century, when questions about the health effects of smoking became a topic of widespread discussion, tobacco companies undertook a multi-faceted campaign to allay the public's fears. As terms like "smoker's cough" and "coffin nails" (referring to cigarettes) began to appear in the popular vernacular, tobacco marketers recognized the need to counter this threat to their livelihood. One strategy was to use endorsements by healthy and vigorous-appearing singers, radio stars, and actors. Another was to raise fears over weight gain: "Reach for a Lucky instead of a sweet." Among the more reprehensible tactics was the utilization of the image of the noble and caring physician to sell cigarettes: doctors were depicted both as satisfied and enthusiastic partakers of the smoking habit (e.g., "More doctors smoke Camels"). Images of medical men (and a few token women) appeared under warm reassurances of the safety of smoking. Frequently, images appeared of a head-mirrored "throat doctor," smiling benignly, while indicating that the company's product would do no harm. Indeed, many cigarette ads, especially for menthol brands, suggested a therapeutic soothing benefit from smoking. Liberal use was also made of pseudo-scientific medical reports and surveys. Our intention is to tell, principally through advertising images-the story of how, between the late 1920s and the early 1950s, tobacco companies used deceptive and often patently false claims in an effort to reassure the public of the safety of their products.

Impact of corrective health information on consumers' perceptions of "reduced exposure" tobacco products

OBJECTIVE

To determine whether providing corrective health information can reduce the tendency of consumers to believe that the implied marketing message that two "potentially reduced exposure products" (PREPs) are safer than regular cigarettes.

DESIGN

Face-to-face interviews with smokers assigned to one of four conditions, which varied in terms of the presence or absence of health information that qualified claims made in advertising for two PREPs.

SUBJECTS

A convenience sample of 177 smokers in Boston area.

INTERVENTIONS

Health information detailed the extent to which exposure to toxins and health risks of the brands were unknown.

MAIN OUTCOME MEASURES

Respondents' assessments of the health risks and toxicity of the two combustible PREPs, Advance and Eclipse.

RESULTS

The health information had a modest but significant effect on ratings of health risk, and reduced perceptions that switching to the new brands would lower a smoker's risk of cancer (OR 0.75; p<0.05). The health information had no effect on perceptions of toxicity.

CONCLUSIONS

A small dose of corrective information was effective in tempering smokers' perceptions. A higher dose of public health campaigns would be needed to affect misperceptions likely to follow a full-scale tobacco marketing effort.

Potential reduced exposure products (PREPs) in industry trial testimony

OBJECTIVE

To identify patterns in trial testimony that may reflect on the intentions or expectations of tobacco manufacturers with regard to the introduction of potential reduced exposure products (PREPs).

DESIGN

Research was conducted using the Deposition and Trial Testimony Archive (DATTA) collection of trial testimony and depositions housed online at Tobacco Documents Online (www.tobaccodocuments.org). Relevant testimony was identified through full-text searches of terms indicating PREPs or harm reduction strategies. The role and function of PREPs in testimony were classified according to common and contrasting themes. These were analysed in the context of broader trial arguments and against changes in time period and the market.

RESULTS

Analysis of testimony suggests that the failure of PREPs in the market tempered initial industry enthusiasm and made protection of the conventional cigarette market its major priority. The "breakthrough" character of PREPs has been de-emphasised, with trial arguments instead positioning PREPs as simply another choice for consumers. This framework legitimises the sale of conventional brands, and shifts the responsibility for adoption of safer products from the manufacturer to the consumer. Likewise, testimony has abandoned earlier dramatic health claims made with regard to PREPs, which had undermined industry arguments regarding efforts to reduce harm in conventional products. More recent testimony advocates the broad acceptance of independent guidelines that would validate use of health claims and enable the industry to market PREPs to consumers.

CONCLUSION

Trial testimony reflects the changing role and positioning of PREPs by the tobacco industry. The findings are of particular importance with regard to future evaluation and potential regulation of reduced harm products.

Interventions to reduce harm from continued tobacco use

BACKGROUND

It may be reasonable to try to reduce the harm from continued smoking amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products. The interventions evaluated in controlled trials have predominantly attempted to reduce the number of cigarettes smoked.

OBJECTIVES

To assess the effect of interventions intended to reduce the harm from smoking on the following: biomarkers of damage caused by tobacco, biomarkers of tobacco exposure, number of cigarettes smoked, quitting, and long-term health status.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register using free text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. The initial search was in March 2006, updated in March 2007.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions in tobacco users to reduce amount smoked, or to reduce harm from smoking by means other than cessation. Outcomes were change in cigarette consumption, markers of cigarette exposure and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We pooled trials with similar interventions and outcomes using a fixed-effect model. Other studies were summarised narratively.

MAIN RESULTS

The 13 included trials all evaluated interventions to help smokers cut down the amount smoked. Self-reported reduction in cigarettes per day (CPD) was validated by reduction in carbon monoxide (CO) levels. Most trials tested nicotine replacement therapy (NRT) to assist reduction. No eligible studies evaluated the use of potentially reduced-exposure products. In a pooled analysis of eight trials, NRT significantly increased the odds of reducing CPD by 50% or more for people using nicotine gum or inhaler or a choice of product compared to placebo (n=3273, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.55 to 2.62). Where average changes from baseline were compared for different measures, CO and cotinine consistently showed smaller reductions than CPD. Whilst the effect for NRT was significant, small numbers of people in either treatment or control group successfully sustained a reduction of 50% or more. Use of NRT also significantly increased the odds of quitting (OR 1.90, 95% CI 1.46 to 2.47). One trial of bupropion failed to detect an effect on reduction or cessation. Four trials of different types of advice and instructions on reducing CPD did not provide clear evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence about long-term benefit to give firm support the use of interventions intended to help smokers reduce but not quit tobacco use. Some people who do not wish to quit can be helped to cut down the number of cigarettes smoked and reduce their carbon monoxide levels by using nicotine gum or nicotine inhaler. Because the long-term health benefit of a reduction in smoking rate is unclear this application of NRT is more appropriately used as a precursor to quitting.

Findings and implications from a national study on potential reduced exposure products (PREPs)

Tobacco companies have recently introduced products that they claim have reduced toxins and carcinogens, and that they say may be less harmful to smokers. These are potential reduced exposure products, or PREPs. This study measured smokers' awareness of PREPs, use of PREPs, interest in trying PREPs, and beliefs about the regulation of PREPs. This study was based on nationally representative data collected in 2002 and 2003 through the American Smoking and Health Survey. The final sample included 1,174 adult smokers. Descriptive and multivariate analyses were conducted to produce estimates and explore potential correlates of the outcomes. A total of 41.9% of adult smokers reported having heard of at least one of the PREPs measured, and 11.0% reported having tried one of these products. Half of adult smokers (49.9%) said they would like to try PREPs. Interest in trying PREPs was associated with having made a quit attempt, being concerned about the effect of smoking on one's health, and having a household income of less than US dollars 20,000. About half of adult smokers (49.1%) incorrectly believed that PREPs are evaluated for safety by the government before being placed on the market, and 84.2% believed that the government should evaluate the safety of PREPs before they are sold to consumers. This study provides new and timely information on the use of, interest in trying, and beliefs about the regulation of PREPs among a nationally representative sample of adult smokers. With half of adult smokers interested in trying PREPs, the need for concrete scientific evidence on the potential impact of these products is critical.

Calculated Cancer Risks for Conventional and “Potentially Reduced Exposure Product” Cigarettes

Toxicant deliveries (by machine smoking) are compiled and associated cancer risks are calculated for 13 carcinogens from 26 brands of conventional cigarettes categorized as "regular" (R), "light" (Lt), or "ultralight" (ULt), and for a reference cigarette. Eight "potentially reduced exposure product" (PREP) cigarettes are also considered. Because agency-to-agency differences exist in the cancer slope factor (CSF) values adopted for some carcinogens, two CSF sets were used in the calculations: set I [U.S. Environmental Protection Agency (EPA)-accepted values plus California EPA-accepted values as needed to fill data gaps] and set II (vice versa). The potential effects of human smoking patterns on cigarette deliveries are considered. Acetaldehyde, 1,3-butadiene, and acrylonitrile are associated with the largest calculated cancer risks for all 26 brands of conventional cigarettes. The calculated risks are proportional to the smoking dose z (pack-years). Using CSF set I and z = 1 pack-year (7,300 cigarettes), the calculated brand-average incremental lifetime cancer risk ILCR(1)(acetaldehyde) values are R, 6 x 10(-5); Lt, 5 x 10(-5); and ULt, 3 x 10(-5) (cf. typical U.S. EPA risk benchmark of 10(-6)). These values are similar, especially given the tendency of smokers to "compensate" when smoking Lt and ULt cigarettes. ILCR(1)(subSigma-lung) is the brand-average per pack-year subtotal risk for the measured human lung carcinogens. Using CSF set I, the ILCR(1)(subSigma-lung) values for R, Lt, and ULt cigarettes account for <or=2% of epidemiologically observed values of the all-smoker population average per pack-year risk of lung cancer from conventional cigarettes. R(PREP) (%) is a science-based estimate of the possible reduction in lung cancer risk provided by a particular PREP as compared with conventional cigarettes. Using CSF set I, all R(PREP) values are <2%. The current inability to account for the observed health risks of smoking based on existing data indicates that current expressed/implied marketing promises of reduced harm from PREPs are unverified: there is little reason to be confident that total removal of the currently measured human lung carcinogens would reduce the incidence of lung cancer among smokers by any noticeable amount.

UK smokers' and ex-smokers' reactions to cigarettes promising reduced risk

AIMS

This study evaluated the impact of exposure to information about a novel cigarette claiming to reduce exposure to tobacco toxins ('potential reduced exposure product' cigarette or PREP-C) on smokers' and ex-smokers' perceptions of PREP-C, on quit interest among smokers and on interest in resuming smoking among ex-smokers.

DESIGN AND PARTICIPANTS

A random digit-dialed telephone survey was conducted in the United Kingdom with 500 current smokers and 106 ex-smokers who had quit within the last 2 years.

INTERVENTION

The interviewer described a novel cigarette that claimed to significantly reduce exposure to smoke toxins.

MEASUREMENTS

Respondents' interest in purchasing the PREP-C, beliefs about its safety and risk reduction and smokers' quit interest, as measured by stage of change, before and after exposure to PREP-C information.

FINDINGS

Among smokers, 76.5% were interested in purchasing PREP-C; interest did not vary by stage of change. Almost all smokers (90.6%) thought PREP-C was safer than regular cigarettes, with 5.4% indicating that the health risks were equivalent to not smoking at all. Exposure to PREP-C description did not change quit interest. Among ex-smokers, 5.6% believed PREP-C carried no health risk and 7.1% expressed purchase interest.

CONCLUSIONS

Smokers and ex-smokers interpreted claims of reduced toxin exposure as reduced health risk and responded positively towards PREP-Cs. With the increasing introduction of PREP-Cs world-wide, evaluation of these products and their claims on quitting among smokers and on relapse among ex-smokers is a matter of public health urgency.

Cessation among smokers of "light" cigarettes: results from the 2000 national health interview survey

OBJECTIVES

A large proportion of smokers erroneously believe that low-nicotine/low-tar cigarettes, also called "light cigarettes" or "lights," reduce health risks and are a rational alternative to smoking cessation. However, the availability of light cigarettes may deter smoking cessation.

METHODS

We analyzed the 32374 responses to the US 2000 National Health Interview Survey. Current and former smokers ("ever-smokers") were asked if they had ever used a lower tar and nicotine cigarette to reduce health risks. Multivariable logistic regression identified determinants of lights use and smoking cessation. Results were weighted to reflect the national population.

RESULTS

Of 12285 ever-smokers, 37% (N=4414) reported having used light cigarettes to reduce health risks. Current abstinence was less often reported by ever-smokers who had previously used light cigarettes than by ever-smokers who had never used lights (37% vs 53%, P<.01). Adjusted odds of cessation among ever-smokers who had used light cigarettes relative to those who had never used lights were reduced by 54% (adjusted odds ratio=0.46, 95% confidence interval=0.41, 0.51).

CONCLUSIONS

Use of light cigarettes was common and was associated with lower odds of current smoking cessation, validating the concern that smokers may use lights as an alternative to cessation.

Evaluating smokers' reactions to advertising for new lower nicotine quest cigarettes

Quest cigarettes are a relatively new (2003) product that has been marketed as a way for smokers to gradually reduce the nicotine they receive from cigarettes in order to, according to marketing materials, become nicotine free. However, despite lower levels of nicotine, Quest cigarettes do not have reduced tar levels and, thus, still pose health hazards. This study evaluated beliefs about Quest cigarettes following exposure to a single print advertisement among 200 regular smokers who had never heard of the brand itself. Descriptively, smokers made several specific false inferences about Quest cigarettes after exposure (i.e., lower in tar, healthier, less likely to cause cancer). Two individual-differences variables, need for cognition and perceived vulnerability, moderated smokers' health beliefs about Quest cigarettes.

Ever users versus never users of a "less risky" cigarette

The authors surveyed 173 smokers who purchased and 114 smokers who knew about but did not purchase Eclipse--a tobacco industry product that is advertised as a reduced risk cigarette. Most low-tar/nicotine cigarette users who purchased Eclipse believed Eclipse was safer than low-tar/nicotine cigarettes both for their own health (73%) and for the health of others around them (86%). Additionally, many viewed Eclipse as a step toward quitting (53%). The authors did not identify robust predictors of Eclipse use. At 6 months follow-up, Eclipse users were as likely to have tried to quit as nonusers; however, the small sample size does not rule out the possibility that Eclipse use undermines quit attempts. The authors conclude that almost all users believe Eclipse is safer than low-tar cigarettes.

New tobacco products: do smokers like them?

BACKGROUND

There is little information about smokers who tried potentially reduced exposure products (PREPs) (Eclipse, Omni, Advance Lights, Accord, or Ariva), why they tried them, if they liked these products, and if they will continue to use them.

OBJECTIVES

The objectives of this qualitative study were to understand: (1) how smokers who tried PREPs learned about them, (2) reasons for first trying PREPs, (3) which PREP(s) they tried, (4) what they thought of the product at first trial, (5) reasons for continuing or discontinuing use, and (6) whether they would recommend PREPs to others.

DESIGN

In October 2002, 16 focus group sessions were conducted with current cigarette smokers aged 30-50 years: eight groups in Chattanooga, Tennessee, and eight in Dallas, Texas. Specific focus groups were composed of white men, white women, African American men, African American women, Hispanic men, or Hispanic women.

RESULTS

The majority of the participants learned about PREPs through advertising or promotion, family, friends, and co-workers; major reasons given for first trying PREPs were that the products were free or inexpensive, they wanted to stop smoking, they believed the product claims of fewer health risks, or they were curious; most of them tried Eclipse probably because the focus groups were conducted in the same cities where Eclipse was introduced; most participants did not like PREPs; most discontinued the use of PREPS, some who continued to use them did so infrequently and also kept smoking their regular brands of cigarettes; and most would not recommend PREPs, although a few might recommend them to specific groups (for example, new smokers, the young, women, curious or health conscious people).

CONCLUSIONS

Although most established smokers did not like the PREPs they tried and will not recommend them to anyone, a minority of established smokers believe that there may be a market for these products.

The time for tobacco industry sponsored PREP evaluation has arrived

Rigorous and objective industry funded evaluation of potential reduced exposure products will require innovation and flexibility, but must begin now

Methods to assess potential reduced exposure products

The availability of tobacco products purported to reduce toxin exposure or potentially reduce health risks necessitates the development of methods and identification of biomarkers that can be used to assess these products. These assessments occur on multiple levels and stages, from identifying constituents in the tobacco products and smoke, to human exposure and health effects trials, to postmarketing surveillance. A conference of multidisciplinary experts was convened to present and discuss methods and biomarkers to assess these products and to consider the infrastructure necessary to facilitate the evaluation process. Although no currently available set of measures was thought to be sufficient for determining the relative health risk of potential reduced exposure products, this paper provides a blueprint for future research toward this end.

Lessons from the history of tobacco harm reduction: The National Cancer Institute's Smoking and Health Program and the "less hazardous cigarette"

Scientists and public health practitioners are sharply divided today over the risks and benefits of tobacco harm-reduction strategies. At the same time, a range of novel tobacco products is being marketed with claims of reduced exposure or risk. Current scientific efforts to study tobacco products and harm reduction should be informed by past experience. During the 1960s and 1970s, there was substantial support within government and academia, as well as among voluntary health organizations, for efforts to modify tobacco products to reduce harm. This paper analyzes the former National Cancer Institute (NCI) Smoking and Health Program, which, between 1968 and 1980, pursued the development of "less hazardous" cigarettes as its primary goal. During this period, the program spent over dollar 50 million on contract research, of which 74% went toward biological and chemical analysis of modified cigarettes, 9.6% to epidemiological studies of risk factors, and only 1.4% to studies evaluating smoking cessation or prevention programs. NCI officials predicted during the mid-1970s that new "low-tar" cigarette brands would substantially reduce smoking-related mortality, but by 1978 the research agenda began to change in response to a reorganization of NCI research activities, modification of government antismoking efforts, and an emerging understanding of nicotine addiction that challenged key scientific assumptions. In retrospect, the program suffered from significant weaknesses that severely limited the likelihood that it would generate knowledge beneficial to public health, including a research agenda that failed to include surveillance and behavioral research, tobacco industry influence of the research agenda, and a lack of access to information about the characteristics of products on the market. There exists today a need for a public health-oriented research agenda on tobacco products and harm reduction, but current efforts should include input from a diverse range of disciplines, collect data on users' behavior, and limit the involvement of industry scientists.

Smoker awareness of and beliefs about supposedly less-harmful tobacco products

BACKGROUND

Cigarette manufacturers in the United States have begun marketing cigarette brands claiming to reduce smokers' exposure to selected toxins in tobacco smoke. Little data exist on smokers' awareness, use, and beliefs about these products.

METHODS

Data from the U.S. arm of the International Tobacco Control Policy Four-Country Survey (ITC-4), a telephone survey of 2028 adult current cigarette smokers in the United States conducted between May and September 2003, were analyzed. Respondents were asked to report their awareness, beliefs, and use of products marketed as less harmful than traditional cigarettes and of smokeless tobacco (SLT) products.

RESULTS

Close to 39% of smokers were aware of "less-harmful" cigarettes, but only 27% of them could name a specific brand of such cigarettes. The brand named most often was Quest (25.7%), followed by Eclipse (7.6%), Winston (5.7%), herbal cigarettes (3.3%), "smoke-free" cigarettes (2.9%), Marlboro Blend #27 (1.9%), and Omni (1.9%). Of those who named a brand, 25% believed such products were less harmful than "ordinary cigarettes." In contrast, 82% of cigarette smokers were aware of SLT products, but only 10.7% of these believed that SLTs were less harmful than ordinary cigarettes.

CONCLUSIONS

Smokers hold beliefs about the relative safety of supposedly less-harmful tobacco products that are opposite to existing scientific evidence. These results highlight the need to educate smokers about the risks of alternatives to conventional cigarettes, and the need to regulate the advertising and promotion of such alternatives.